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Resumo
A empatia representa um papel de relevo na relação entre o fisioterapeuta e os seus pacientes. Os fisioterapeutas estão sujeitos a um contexto de trabalho e carreira profissional particulares e expostos a exigências elevadas, o que os torna mais susceptíveis ao burnout. A empatia e burnout podem representar pólos opostos no contexto da relação clínica, sofrendo influências de género, condições profissionais e estabelecerem entre si uma relação circular, influenciando-se mutuamente.
Objectivo. Este estudo tem como objectivos (1) estudar a relação da empatia e
burnout com as características profissionais e o sexo e (2) identificar as relações entre empatia e burnout.
Desenho. Neste estudo seguiu um modelo de investigação transversal.
Métodos. Foi aplicado um questionário original para caracterização sócio-demográfica
e profissional de um a população de 106 fisioterapeutas exclusivamente em prática clínica privada. A Jefferson Scale of Physician’s Empathy (JSPE) e Maslach Burnout
Inventory (MBI) na sua versão portuguesa foram utilizadas para avaliar a Empatia e o
Burnout.
Resultados. A maioria dos fisioterapeutas estudados revelou um nível satisfatório de
atitudes empáticas (115.3 - SD 9.8), significativamente maior nas mulheres (P= 0.009). Foram detectados níveis moderados a altos de burnout, com 49.1% na subescala Exaustão Emocional, 33.9% na subescala Despersonalização e 31.2% na subescala Realização Pessoal, distribuídas homogeneamente por ambos os sexos. As fisioterapeutas com maior empatia demonstraram na avaliação do burnout, níveis mais baixos de Exaustão Emocional e Despersonalização. Ambos os sexos apresentaram uma correlação positiva entre a subescala Realização Pessoal (nível baixo de burnout) e a empatia.
Limitações. O desenho transversal do estudo limita inferências de causalidade,
numero limitado de participantes e ambiente de trabalho específico dificulta a generalização dos resultados obtidos.
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Conclusões. A Empatia apresenta valores mais elevados nos fisioterapeutas do sexo
feminino; o total da amostra revelou uma correlação positiva da empatia com o nível de educação mas não se encontrou relação com a idade ou com os anos de experiencia profissional. A empatia apresentou-se negativamente associada ao burnout nas fisioterapeutas e positivamente associada à realização pessoal em ambos os sexos.
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Abstract
Background - Empathy can represent a major role in the relationship between physical
therapists and their patients. Submitted to particular work context and carrier conditions and exposed to high demands, physical therapy professionals become more susceptive to burnout. Empathy and burnout can represent opposite roles in clinical relationship, be influenced by gender, work conditions and circularly influence each other.
Objective - This study aimed (1) to study the relationship of empathy and burnout with
professional conditions and gender and (2) to identify the relationships between empathy and burnout
Design - A cross-sectional study design was used
Methods - A questionnaire was applied to characterize demographic and professional
variables in a population of 106 physical therapists in exclusive private practice. Jefferson Scale of Physician’s Empathy (JSPE) and Maslach Burnout Inventory (MBI) were used to assess Empathy and Burnout.
Results - The majority of the physical therapists studied revealed adequate levels of
empathic components (115.3 - SD 9.8), significantly higher in female than in male professionals (P= 0.009). Moderate to high levels of burnout were detected, distributed homogeneously by gender, with 49.1% in Emotional Exhaustion, 33.9% in Depersonalization and 31.2% in Personal Accomplishment subscales. More empathic female physical therapists showed lower levels of Emotional Exhaustion and Depersonalization in burnout assessment. Both sexes presented a positive correlation between Personal Accomplishment subscale (lower burnout level) with higher empathy scores.
Limitations - The cross sectional design limited inferences of causality; limited number
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Conclusions - Empathy presented higher values in female Physiotherapists; the total
sample revealed a positive correlation of empathy with educational achievement, but not with age or years of professional practice. Empathy presented negatively associated with burnout in females and positively associated with Personal Accomplishment regardless physiotherapist gender.
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Introduction
Empathy in the clinical context
Human beings share an innate desire to be understood [1-2]. This understanding is the foundation of interpersonal relationships in health care and also an important factor in the efficacy of health care procedures. Several studies have examined both the impact of the patient-clinic relationship in treatment compliance, therapeutic results and the patients' satisfaction with the care received [3-4].
Empathic qualities allow health professionals to respond to biomedical and psychosocial needs of their patients, has they feel scared, frustrated and vulnerable seek support and safety in clinicians [5-6].
Although several authors agree on the important role played by empathy in clinical relationship [7], it’s definition is not free of controversy [2, 8]. In general empathy is defined as a construct involving cognitive, affective, emotional and behavioral components [3, 9-11].
In clinical empathy, the cognitive component is defined as the ability to understand patient's personal feelings and experiences, as well as the ability to see the world through another person's perspective, coupled with an attitude of understanding and tolerance [3, 9-10, 12-13].
The affective and emotional components include the ability to understand other people's feelings and experiences, as well as the ability to share feelings with others [3, 9-10, 12].
The behavioral dimension regards the ability to show and communicate the understanding of other people's emotions to themselves in an appropriate manner through verbal and non-verbal signs [11-12, 14].
Morse and co-workers [12] descriptive in their empathy model, in addition to these dimensions, the moral dimension defined as the motivation to seek the good in others, linked to attributes such as respect, pro-social behavior [15], moral reasoning [16] and the reduction of bad clinical practices [17-18].
On the other hand, the understanding of the patients' emotional status must be balanced, since an over participation in the patient's emotional experiences may lead to a loss of clinical objectivity [18] and blur the line between clinician and patient [3].
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In summary clinical empathy has been associated with more positive clinical results[3, 18-21], reduction of patient complaints[22], increase in patient [17, 19-21] and clinicians' satisfaction [23], a reduction of conflicts and improvement in trust [19, 21, 24]. Positive results have also been referred in patient's strength and ability to cope with the illness [19, 25], and in patient's feeling of being supported and understood. [3]
Empathy in Physical therapy
The development of a professional and empathic patient-clinician relationship by physical therapists demands both innate and acquired skills [14]. Among these skills, the establishment of an adequate communication through active listening (absorbing verbal and nonverbal cues [26]) is a key component. Nevertheless, the increased responsibility and pressure to treat a growing number of patients hinder physical therapists clinical communication leaving them with less time with their patients [14]. Furthermore, it is often difficult to establish visual contact during some physical therapy treatments, enabling non-verbal communication and the identification of unexpressed feelings [27]. Verbal and non verbal cues from physical therapist are also essential. In a recent study, the words chosen by the health professionals to describe pain secondary to treatment procedure increased patient’s' sensibility to pain [28-30].
Empathy also involves the physical therapist's ability to overcome prejudices and judgments, adopting an "open mind" position [3, 29].
Emotions have to be explored, validated and supported in physical therapist- patient interaction, in order to optimize clinical results [30-31]. Nevertheless, several studies have shown that a large number of health professional fail to recognize emotions, underestimating an invitation to participate, relate to and understand the patient's needs [3], restricting attention to facts and discarding emotional meanings [32]. The adequate response to the patients emotions benefit the clinical relationship, increasing the patient's confidence, diminishing anxiety and improving compliance to treatment [32-33]. Emotional empathy [34] is therefore the result of a harmonization between cognitive concern and the ability to emotionally understand the other.
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The development of empathic strategies increases the health professionals' ability to cope with their own feelings of anger and frustration [35], enabling them to prevent and manage conflict situations. An open attitude, facilitating the acceptance of patient feedback [36], permits to avoid rigid and controlling positions [37-38].
The specificities of the physical therapist-patient relationship demand a professional commitment regarding proximity and physical contact with the patient. Some studies divide the proximity zone between clinician/patient in: intimate <45cm, personal 45-120cm, social 1.2-2m and public 2-3.5m [39]. Since most of the physical therapists' professional activity takes place within the patient's "intimate zone", empathic communication is an important pre-requisite for good clinical practice, in order to facilitate the occurrence of physical proximity without being intimate.
Although scarce, empirical evidence is available of the relevance of an empathic relation in the Physical therapeutic context. Empathy in physical therapy may, as in other clinical settings is considered a therapeutic tool. According to Stenmar and Nordholm, in addition to the importance of manual techniques in physical therapy, physical therapist-patient relationship can represent a relevant factor in physical recovery [40]. Spending time with the patient, understanding his or her feelings and acting compassionate can prove more important than the length or number of physiotherapy sessions held. In a recent study patients showed their appreciation towards the physical therapists that had been kind, friendly, nice, and professional and displayed a genuine interest in their patients [41].
The adoption of patient-centered approach, for example, can increase patient's satisfaction and clinical results even in a single session. Establish an adequate communication, inform, be open to questions or doubts [41], contribute to support and understand patients needs.
Hall and co workers conclude that “the alliance between therapist and patient appears to have a positive effect on treatment outcome in physical rehabilitation settings” [42].
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Burnout and Empathy in Physical therapy
It is undeniable that the health professionals' occupational stress has become a concern both to the health professionals themselves and the health institutions [43].
Several studies in different clinical areas revealed high levels of stress and pointed to their negative consequences not only for the clinicians and patient's physical and mental health but also for the quality of the provided health care, with adverse effects on the quality evaluation of health institutions [43-44].
Lack of professional autonomy, negative organizational characteristics or poorly defined hierarchy, absence of professional and social recognition and, especially, interpersonal conflicts within the professional context have been considered causes leading to high levels of stress in physiotherapists [43]. Number of patients, hours of work and diminish human resources, on the other hand, classically being regarded as responsible for significant amount of professional stress [45]. Although emotional strain of dealing with a heavy work load may lead the clinician to burnout, feelings of being overworked, depend on the strengths and weaknesses of each health care worker and his or her personal resistance to stress [45].
The Burnout Syndrome has been described since the 70's as a result of physical and psychological exhaustion in health professionals. Maslach defines burnout as resulting from emotional exhaustion (lack of emotional and personal resources, the experience of feeling emotionally exhausted), depersonalization (negative feelings and attitudes towards others, treating patients as objects) and absence/reduced personal accomplishment (feelings of poor professionalism implying low levels of self-esteem and ambition) [43] with a consequent attitude of professional indifference, isolation and disinvestment in different areas of personal functioning [45-46].
The Burnout Syndrome can be regarded as a reaction to chronic stress occurring in professionals who care, treat or have to personally deal with other individuals [43]. In clinicians, burnout can be seen as a result of continuous demands accompanied by insufficient resources to deal with the demands posed by the surrounding environment [44, 47]. Feelings of exhaustion, helplessness and defeat are frequent, but need to be distinct from the concepts of dissatisfaction with work, stress or depression. The occurrence of Burnout depends not only on occupational stress but
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also on personal variables (personality, coping strategies, and social support, among others). Freudenberg and Maslach[48] have drawn attention to the fact that this phenomenon can affect normal individuals, representing in fact a common phenomenon characterized by emotional exhaustion and a lack of motivation and engagement [47]. Burnout syndrome can disrupt professional performance due to the development of negative feelings and attitudes towards the patients as a consequence of emotional exhaustion and finally perform a negative evaluation of themselves and feel disappointed with the results of their work [44].
Regarding physical therapists, insufficient or low salaries, lack of prestige, rigid organizational contexts, patient characteristics [49] excessive demands [50] and particularly work overload are factors associated to burnout syndrome. As a result, this may lead to an increase in absenteeism [51], a reduction of productivity, negative attitudes, interpersonal conflicts and a diminishing sense of responsibility and ethics [52].
Similarly to other health professionals, physical therapists are strong candidates for developing burnout, due to spending most of their careers deeply involved with their patients [45]. The frequent contact with disability, physical and psychological pain, patients failure in achieving total recovery, or requested to deal with permanent disability, request from physiotherapist empathic skills in order to eventually protect them from low self-esteem and low accomplishment [50].
The present work examines the relationship between empathy and burnout levels in a sample of physical therapists working exclusively in private practice. Empathic relationship can improve adherence to treatment and seem to contribute to more rapid recovery, essential to physical therapy success. From physical therapist point of view effective communication and empathic attitude can improve personal accomplishment and reduce susceptibility to burnout. We intended to study the association of empathy and burnout with professional and socio demographic physical therapist variables, particularly gender differences. It is also our aim to explore the relation between empathic dimensions assessed in clinical context and burnout in the same population. Recommendations to physical therapist to develop and train communication and emphatic skills could in addition to benefit therapeutic goals, protect professionals from emotional exhaustion and burnout.
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